K. Bennett - Disability Advocate

DISABILITY EVALUATION There is absolutely no obligation in filling out this form. The submittion of this form does not in any way create a Representative-client relationship In order for your claim to be evaluated, this form must be filled out as completely and accurately as possible, especially the Disability and Work History information. This information is completely confidential and cannot be used for any purpose other than your evaluation. Because of HIPAA laws, Social Security regulations and NOSSCR restrictions, we are bound to keep all information confidential. Evaluation Information Name: Address: City, State, Zip: Age: Email Address: Phone Number: Marital Status: Single Married Highest Education Level: 6th grade or less 11 grade or less Highschool College What level of the Social Security program are you at? Not filed yet. Initial claim. Reconsideration. Hearing. Have you appointed a disability representative/advocate yet? Yes No Are you being treated by a Doctor, clinic or other medical facility?: Yes No Discribe your disability(s) as complete and accurate as possible. List the medications you are on. Are you presently working?: Full Time Part Time Not Working If not working, when was your last day of work: List the jobs and job titles of work that you have done in the last 15 years? When you have finished, hit send button below. The form may take a few seconds so please do not re-submit